This document outlines a presentation on root cause analysis (RCA). The objectives are to gain an overview of the problem solving process, learn how to apply RCA tools like 5 whys and cause-effect diagrams to identify root causes, learn how to prioritize root causes with a Pareto chart, and understand pitfalls. The program outline covers an introduction to RCA, an overview of the problem solving process, using 5 whys and cause-effect diagrams for analysis, and using a Pareto chart for prioritization while avoiding common pitfalls.

1. IDENTIFY,ELIMINATE,PREVENT
Presenter : Gloria Kgagabi
2015-06-12
ROOT CAUSE ANALYSIS

2. OBJECTIVES
• Gain an overview of a problem solving process.
• Learn how to apply common root cause
analysis tools such as 5 whys and cause
effect diagrams to identify root causes.
• Learn how to prioritise root causes with a
pareto chart.
• Understand the pitfalls in root cause
analysis.
2015-06-12

3. PROGRAM OUTLINE
• Introduction to root cause analysis.
• Overview of a problem solving process.
• Root cause analysis using 5 whys.
• Root cause analysis using cause effect
diagrams.
• Root cause prioritisation using pareto
chart.
• Pitfalls to avoid.
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4. 2015-06-12

5. “When we
fail to grasp
the
systematic
source of
problems,
we are left
to ‘push on`
symptoms
rather than
eliminate
causes”
-Peter Senge
the fifth discipline
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6. What is root cause analysis ?
 Root cause analysis (RCA) is a technique that helps guide
people to discover and understand the initiating cause(s) of a
problem, with the goal of determining missing or inadequately
applied that prevent reoccurrence(s).
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7. Root cause-the evil at the
bottom
• The root cause is the – “evil at the bottom” that sets in motion
the entire cause- and –effect cause chain causing the
problem(s)
Symptom
Visible
problem
Higher- level cause
First- level cause
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8. Why Root cause analysis ?
• RCA helps to identify what, how and why an
event or failure occurred.
• Root causes are underlying, are reasonably
identifiable, can be controlled by management
and allow for the generation of solutions.
• Only when you are able to determine why an
event or failure occurred will you be able to
specify workable corrective and preventative
measure(s)
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9. Principles of RCA
•System thinking approach
•Prevention of reoccurrence
•Pareto principle
•Employee engagement
•Continuous improvement
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10. Overview of problem
solving process
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11. Root cause analysis
Albert Einstein
“Problems that exist
in the world cannot
be solved by the
level of thinking
that created them”
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12. A simple problem solving
process
DEFINE THE
PROBLEM
COLLECT DATA
IDENTIFY ROOT CAUSES
IMPLEMENT
COUNTERMEASURES
EVALUATE AND FOLLOW
UP
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13. Dealing with root causes
• Solutions must deal with root causes not symptoms.
• Ask “WHY”? five times to get to the root cause.
• Use the cause and diagram.
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15. Every defect is a treasure !
Kiichiro Toyada-founder of
toyota
“Every defect is a
treasure, if the
company can
uncover its and
work to prevent it
across the
corporation”
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16. Benefits of 5 whys
• Helps to identify the root of a
problem.
• Determines the relationship between
different root causes of a problem.
• One of the simplest tools , easy to
complete without statistical analysis.
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17. Example of 5 whys
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18. Cause and effect diagram
PURPOSE:
• To capture the casual relationship between cause and
effect.
• To stratify the causes into meaningful groupings
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19. Cause and effect
diagram(Manufacturing)
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20. Manufacturing example
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21. Combining 5 whys and cause
effect diagrams
• The 5 whys can be used individually or as a part
of the C & E diagram.
• The C & E diagram helps you to explore all
potential or real causes that result in a single
defect or failure.
• Once all inputs are established on the fish bone
you can use the 5 whys technique to drill down
to the root causes.
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23. Pareto chart
PURPOSE:
• To show relative significance of the
identified root causes.
WHEN TO USE:
• To differentiate the ‘vital few’ problems or
causes from the ‘trivial many’.
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24. EXAMPLE-Pareto chart
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PITFALLS TO AVOID

26. Pitfalls to avoid
• The use of RCA is focused on who caused the
problem-placing blame instead of finding out
how the problem arises.
• The use of RCA focuses only on analysis rather
than eliminating the problem.
• No one can solve a problem at their desk, involve
relevant stake holders.(Otherwise the problem
will keep on reoccurring).
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THERE IS NO STUPID QUESTION: STUPID
PEOPLE DON’T ASK QUESTIONS.

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